<!--{subtemplate common/header}-->
<script type="text/javascript" src="http://www.fendoujp.com/template/fendou/javascript/jquery.checkForm.1.0.js"></script>
<script type="text/javascript">
jQuery(document).ready(function () {
jQuery('form').checkForm();
});
</script>
<!--custom nav-->
<div id="pt" class="bm cl">
	<div class="z">
		<a href="./" class="nvhm" title="{lang homepage}">$_G[setting][bbname]</a> <em>&rsaquo;</em>
		<a href="javascript:void(0);" title="在线评估"><strong>在线评估</strong></a>
	</div>
</div>
<!--/custom nav-->
<form action="http://www.fendoujp.com/custom.php?mod=assess" method="post">
<div class="wp">
    <div class="fendou_portal_main">
        <div class="fendou_custom_left">
        <!--////////////////////////////////////////////////////-->
            <!--标题-->
                <div class="fendou_title fendou_title_meddle">
                    <div class="fendou_title_img assess"></div>
                </div>
            <!--/标题-->
            <!--评估-->
                <div class="fendou_custom_pinggu">
                    <ul>
                        <li class="pinggu_label">
                            <label for="pinggu_name">姓名</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_name" id="pinggu_name" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_name">请输入姓名</label></li>
                    </ul>
                    <ul class="even">
                        <li class="pinggu_label">
                            <label for="pinggu_pinyin">姓名拼音</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_pinyin" id="pinggu_pinyin" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_pinyin">请输入姓名拼音</label></li>
                    </ul>
                    <ul>
                        <li class="pinggu_label">
                            <label for="pinggu_sex">性别</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="radio" name="pinggu_sex" id="pinggu_sex_1" value="" class="radio" checked/><label for="pinggu_sex_1">男</label>
                            <input type="radio" name="pinggu_sex" id="pinggu_sex_2" value="" class="radio"/><label for="pinggu_sex_2">女</label>
                        </li>
                        <li class="pinggu_msg"><label></label></li>
                    </ul>
                    <ul class="even">
                        <li class="pinggu_label">
                            <label for="pinggu_birthday">出生年月日</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_birthday" id="pinggu_birthday" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_birthday">请输入出生年月日</label></li>
                    </ul>
                    <ul>
                        <li class="pinggu_label">
                            <label for="pinggu_cn_domicile">户籍地</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_cn_domicile" id="pinggu_cn_domicile" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_cn_domicile">请输入户籍地</label></li>
                    </ul>
                    <ul class="even">
                        <li class="pinggu_label">
                            <label for="pinggu_email">电子邮件</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_email" id="pinggu_email" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_email">请输入电子邮件</label></li>
                    </ul>
                    <ul>
                        <li class="pinggu_label">
                            <label for="pinggu_tel">电话</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_tel" id="pinggu_tel" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_tel">请输入电话</label></li>
                    </ul>
                    <ul class="even">
                        <li class="pinggu_label">
                            <label for="pinggu_qq">QQ号码</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_qq" id="pinggu_qq" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_qq">请输入QQ号码</label></li>
                    </ul>
                    <ul>
                        <li class="pinggu_label">
                            <label for="pinggu_cn_address">现住址</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_cn_address" id="pinggu_cn_address" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_cn_address">请输入现住址</label></li>
                    </ul>
                    <ul class="even">
                        <li class="pinggu_label">
                            <label for="pinggu_purpose">留学目的</label>
                        </li>
                        <li class="pinggu_input_nomsg">
                            <input type="radio" name="pinggu_purpose" id="pinggu_purpose_1" value="" class="radio" checked/><label for="pinggu_purpose_1">语言学校</label>
                            <input type="radio" name="pinggu_purpose" id="pinggu_purpose_2" value="" class="radio"/><label for="pinggu_purpose_2">本科课程</label>
                            <input type="radio" name="pinggu_purpose" id="pinggu_purpose_3" value="" class="radio"/><label for="pinggu_purpose_3">专升本课程</label>
                            <input type="radio" name="pinggu_purpose" id="pinggu_purpose_4" value="" class="radio"/><label for="pinggu_purpose_4">硕士课程</label>
                            <input type="radio" name="pinggu_purpose" id="pinggu_purpose_5" value="" class="radio"/><label for="pinggu_purpose_5">博士课程</label>
                        </li>
                    </ul>
                    <ul>
                        <li class="pinggu_label">
                            <label for="pinggu_education">学历</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="radio" name="pinggu_education" id="pinggu_education_1" value="" class="radio" checked/><label for="pinggu_education_1">高中</label>
                            <input type="radio" name="pinggu_education" id="pinggu_education_2" value="" class="radio"/><label for="pinggu_education_2">专科</label>
                            <input type="radio" name="pinggu_education" id="pinggu_education_3" value="" class="radio"/><label for="pinggu_education_3">本科</label>
                            <input type="radio" name="pinggu_education" id="pinggu_education_4" value="" class="radio"/><label for="pinggu_education_4">硕士</label>
                            <input type="radio" name="pinggu_education" id="pinggu_education_5" value="" class="radio"/><label for="pinggu_education_5">博士</label>
                        </li>
                        <li class="pinggu_msg"><label></label></li>
                    </ul>
                    <ul class="even">
                        <li class="pinggu_label">
                            <label for="pinggu_school_last">毕业学校</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_school_last" id="pinggu_school_last" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_school_last">请输入毕业学校</label></li>
                    </ul>
                    <ul>
                        <li class="pinggu_label">
                            <label for="pinggu_professional">专业</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_professional" id="pinggu_professional" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_professional">请输入专业</label></li>
                    </ul>
                    <ul class="even">
                        <li class="pinggu_label">
                            <label for="pinggu_money">可出国资金</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_money" id="pinggu_money" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_money">请输入可出国资金</label></li>
                    </ul>
                    <ul>
                        <li class="pinggu_label">
                            <label for="pinggu_jp_experienced">有/无赴日经历</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="radio" name="pinggu_jp_experienced" id="pinggu_jp_experienced_1" value="" class="radio" /><label for="pinggu_jp_experienced_1">有</label>
                            <input type="radio" name="pinggu_jp_experienced" id="pinggu_jp_experienced_2" value="" class="radio" checked /><label for="pinggu_jp_experienced_2">无</label>
                        </li>
                        <li class="pinggu_msg"><label></label></li>
                    </ul>
                    <ul class="even">
                        <li class="pinggu_label">
                            <label for="pinggu_jp_experienced_date">如有请填写时间</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_jp_experienced_date" id="pinggu_jp_experienced_date" value=""/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_jp_experienced_date">请输入时间</label></li>
                    </ul>
                    <ul>
                        <li class="pinggu_label">
                            <label for="pinggu_refused">有/无拒签史</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="radio" name="pinggu_refused" id="pinggu_refused_1" value="" class="radio" /><label for="pinggu_refused_1">有</label>
                            <input type="radio" name="pinggu_refused" id="pinggu_refused_2" value="" class="radio" checked/><label for="pinggu_refused_2">无</label>
                        </li>
                        <li class="pinggu_msg"><label></label></li>
                    </ul>
                    <ul class="even">
                        <li class="pinggu_label">
                            <label for="pinggu_refused_reason">如有请填写拒签理由</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_refused_reason" id="pinggu_refused_reason" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_refused_reason">请输入拒签理由</label></li>
                    </ul>
                    <ul>
                        <li class="pinggu_label">
                            <label for="pinggu_relationship">经费 支付者与本人关系</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_relationship" id="pinggu_relationship" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_relationship">请输入支付者与本人关系</label></li>
                    </ul>
                    <ul class="even">
                        <li class="pinggu_label">
                            <label for="pinggu_annual_income">年收入</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_annual_income" id="pinggu_annual_income" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_annual_income">请输入年收入</label></li>
                    </ul>
                    <ul>
                        <li class="pinggu_label">
                            <label for="pinggu_area">意向地区</label>
                        </li>
                        <li class="pinggu_input">
                            <select name="pinggu_area" id="pinggu_area" class="require">
                                <option value="0">请选择</option>
                                <option value="1">北海道</option>
                                <option value="2">东北</option>
                                <option value="11">关东</option>
                                <option value="19">北陵</option>
                                <option value="24">中部</option>
                                <option value="31">关西</option>
                                <option value="38">中国</option>
                                <option value="44">四国</option>
                                <option value="49">九州</option>
                                <option value="57">冲绳</option>
                            </select>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_area">请输入意向地区</label></li>
                    </ul>
                    <ul class="even">
                        <li class="pinggu_label">
                            <label for="pinggu_examination_entrance">高考成绩</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_examination_entrance" id="pinggu_examination_entrance" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_examination_entrance">请输入高考成绩</label></li>
                    </ul>
                    <ul>
                        <li class="pinggu_label">
                            <label for="pinggu_examination_entrance_score">高考满分分数</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_examination_entrance_score" id="pinggu_examination_entrance_score" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_examination_entrance_score">请输入高考满分分数</label></li>
                    </ul>
                    <ul class="even">
                        <li class="pinggu_label">
                            <label for="pinggu_examination_entrance_date">高考考试年月</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_examination_entrance_date" id="pinggu_examination_entrance_date" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_examination_entrance_date">请输入高考考试年月</label></li>
                    </ul>
                    <ul>
                        <li class="pinggu_label">
                            <label for="pinggu_examination_japan_score">日语考试成绩</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_examination_japan_score" id="pinggu_examination_japan_score" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_examination_japan_score">请输入日语考试成绩</label></li>
                    </ul>
                    <ul class="even">
                        <li class="pinggu_label">
                            <label for="pinggu_examination_japan_level">日语等级</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_examination_japan_level" id="pinggu_examination_japan_level" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_examination_japan_level">请输入日语等级</label></li>
                    </ul>
                    <ul>
                        <li class="pinggu_label">
                            <label for="pinggu_examination_japan_date">日语考试年月</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_examination_japan_date" id="pinggu_examination_japan_date" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_examination_japan_date">请输入日语考试年月</label></li>
                    </ul>
                    <ul class="even">
                        <li class="pinggu_label">
                            <label for="pinggu_japanese_school">日语学习学校名称</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_japanese_school" id="pinggu_japanese_school" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_japanese_school">请输入日语学习学校名称</label></li>
                    </ul>
                    <ul>
                        <li class="pinggu_label">
                            <label for="pinggu_japanese_school_time">日语学习时间（多少小时？）</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_japanese_school_time" id="pinggu_japanese_school_time" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_japanese_school_time">请输入日语学习时间</label></li>
                    </ul>
                    <ul class="even">
                        <li class="pinggu_label">
                            <label for="pinggu_examination_english_score">英语考试成绩</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_examination_english_score" id="pinggu_examination_english_score" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_examination_english_score">请输入英语考试成绩</label></li>
                    </ul>
                    <ul>
                        <li class="pinggu_label">
                            <label for="pinggu_examination_english_level">英语等级</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_examination_english_level" id="pinggu_examination_english_level" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_examination_english_level">请输入英语等级</label></li>
                    </ul>
                    <ul class="even">
                        <li class="pinggu_label">
                            <label for="pinggu_examination_english_date">英语考试年月</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_examination_english_date" id="pinggu_examination_english_date" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_examination_english_date">请输入英语考试年月</label></li>
                    </ul>
                    <ul>
                        <li class="pinggu_label">
                            <label for="pinggu_school_high_name">高中名称</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_school_high_name" id="pinggu_school_high_name" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_school_high_name">请输入高中名称</label></li>
                    </ul>
                    <ul class="even">
                        <li class="pinggu_label">
                            <label for="pinggu_school_high_date_in">高中入学时间</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_school_high_date_in" id="pinggu_school_high_date_in" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_school_high_date_in">请输入高中入学时间</label></li>
                    </ul>
                    <ul>
                        <li class="pinggu_label">
                            <label for="pinggu_school_high_date_out">高中毕业时间</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_school_high_date_out" id="pinggu_school_high_date_out" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_school_high_date_out">请输入高中毕业时间</label></li>
                    </ul>
                    <ul class="even">
                        <li class="pinggu_label">
                            <label for="pinggu_school_college_name">大学名称</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_school_college_name" id="pinggu_school_college_name" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_school_college_name">请输入大学名称</label></li>
                    </ul>
                    <ul>
                        <li class="pinggu_label">
                            <label for="pinggu_school_college_date_in">大学入学时间</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_school_college_date_in" id="pinggu_school_college_date_in" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_school_college_date_in">请输入大学入学时间</label></li>
                    </ul>
                    <ul class="even">
                        <li class="pinggu_label">
                            <label for="pinggu_school_college_date_out">大学毕业时间</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="text" name="pinggu_school_college_date_out" id="pinggu_school_college_date_out" value="" class="require"/>
                        </li>
                        <li class="pinggu_msg"><label for="pinggu_school_college_date_out">请输入大学毕业时间</label></li>
                    </ul>
                    <ul>
                        <li class="pinggu_label">
                            <label for="pinggu_enter_a_higher_school">是否希望带有升学课程</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="radio" name="pinggu_enter_a_higher_school" id="pinggu_enter_a_higher_school_1" value="" class="radio" /><label for="pinggu_enter_a_higher_school_1">是</label>
                            <input type="radio" name="pinggu_enter_a_higher_school" id="pinggu_enter_a_higher_school_2" value="" class="radio" checked/><label for="pinggu_enter_a_higher_school_2">否</label>
                        </li>
                        <li class="pinggu_msg"><label></label></li>
                    </ul>
                    <ul class="even">
                        <li class="pinggu_label">
                            <label for="pinggu_contact_from_school">是否希望咨询师主动联系</label>
                        </li>
                        <li class="pinggu_input">
                            <input type="radio" name="pinggu_contact_from_school" id="pinggu_contact_from_school_1" value="" class="radio" /><label for="pinggu_contact_from_school_1">是</label>
                            <input type="radio" name="pinggu_contact_from_school" id="pinggu_contact_from_school_2" value="" class="radio" checked/><label for="pinggu_contact_from_school_2">否</label>
                        </li>
                        <li class="pinggu_msg"><label></label></li>
                    </ul>
                </div>
                <div class="fendou_custom_pinggu" style="text-align:center;margin:10px 0 10px 0">
                    <input style=" background:url(http://www.fendoujp.com/template/fendou/images/custom/ok.png) no-repeat; width:110px; height:37px; border:0; color:#fff;cursor: pointer;" type="submit" value=""/>
                    <input style="background: url(http://www.fendoujp.com/template/fendou/images/custom/cancel.png) no-repeat;width:110px; height:37px; border:0; color:#fff;cursor: pointer;" type="submit" value=""/>
                </div>
            <!--/评估-->
        <!--////////////////////////////////////////////////////-->



        <!--////////////////////////////////////////////////////-->
        </div>
        <div class="fendou_portal_right">
            <!--标题-->
            <div class="fendou_title fendou_title_side">
                <div class="fendou_title_img training"></div>
            </div>
            <!--/标题-->
            <div class="fendou_portal_right_top"><!--{block/497}--></div>
        </div>
    </div>
    <div style="border-bottom: 1px solid #CDCDCD;float: left;display: inline;width: 100%;margin:10px 0 10px 0"></div>
</div>
</form>
<!--{subtemplate common/footer}-->